application form for admission to b

8/8/2019 Application Form for Admission to B

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Delhi Technological UniversiTy, Delhi(F m D c f e )

app t F m f adm t t B.T . P m 2010-2011l st d te for receipt of app ic tions is 21-06-2010 (Mond y) . Submit the completed form to the JointRegistrar (Admin.), Delhi Technological University, Shahbad Daulatpur, Bawana Road, Delhi-110042.

Note : (a) Fill up the Form completely. Your application is liable to be rejected, if any of the item is un lledor incomplete.

(b) Read the instructions given in the para 3.10 of prospectus carefully before lling this form.(c) Use Capital letters only.

Application No.

Af x your recent

passport sizephotograph

duly attested by thePrincipal of the

School Lastattended

1. Applicant's Name

2. CODE 2.(a) Region 2.(b) Category 2.(c) Sub-Category 2.(d) Kashmiri Migrant

(D/O) (OP/SC/ST/OB) (CW/PH) (KM)

3. Entrance Examination Details (Candidates should ll AIEEE-2010, All India rank and other details).3.(a) Roll No. 3.(b) Overall Rank 3.(c) Category Rank 3.(d) Marks Obtained

(AIR) (AIR)

(if applicable) (in AIEEE)

4. Sex (Write M for Male, F for Female) 5.(a) Nationality 5.(b) Religion

6.(a) Date of Birth 6.(b) Shortage in age, if anyDay Month Year (if not 17 years on 01-10-2010, then indicate shortage)

7. Indicate the branch codes in order of your preferences (See para 3.10 of prospectus)Order of Preferences

Branch Codes(Note : The options indicated here CANNOT be changed later on . The applicants are required to ll all the

preferences, otherwise the application form will be treated incomplete and is liable to be rejected)

8. Particulars of the Qualifying Examination passed (XII or equivalent, refer to prospectus, Section 3.2)8.(a) Examination Passed8.(b) Board/University

8.(c) Name of the College/Schooland address with Pin code

State / Union Territory Pincode

8.(d) Year of Passing Roll No.8.(e) Marks Obtained Marks Secured Max. Marks

8.(f) PCM % •

English8.(g) Aggregate PCME % •

PhysicsChemistry

I certify that I belong to

Mathematicscategory

Othersand sub-category

Aggregate of results

Signature of the Applican t

I II III IV V VI VII VIII IX X XI XII XIII XIV

M M D D



9. Applicant's Postal Address

Email Mobile Pin Code

10. Permanent Address

Pin Code State of Domicile

11. (a) Father's / Guardian's Name Occupation

Residential Address Of cial Address

Pin Code Pin Code

Tel. (R) Tel. (O)

Mob E-mail

(b) Mother's Name

12. Annual Income of Father / Guardian

13. Local Guardian's Name (in Delhi) Relationship with the applicant

Residential Address Of cial Address

Pin Pin

Tel. (R) Tel. (O)

Mob E-mail



14. Have you passed 'English' as a subject at X or XII class Level? If yes, indicate the higher class.

15. Name of the Highest Examination Name of School/University/Board of the examination

passed in Hindi (class 8, 10 or 12)

16. Certi cate by the Principal of the school last attended.

Certi ed that I have attested the photograph of the applicant Mr./Ms. ...........................................................................

pasted on rst page by signing across the same. I further certify that the information given at items no 6(a), 8, 14 & 15

is correct as per our record.

The conduct of the applicant has been satisfactory and he/she bears a good moral character.

Signature of the Principal

Seal of the School/College of School/College where the Applicant studied last

Name and address of the School / College last attended (with Pin Code)

State Pin Code

17. List of Enclosures (tick R in appropriate boxes) (Photocopies only)

1. AIEEE Admit Card

2. AIEEE Score Card

3. Class X (Date of Birth Certi cate)

4. Class XII Marks Sheet

5. Category Certi cate (SC/ST/OBC) as applicable

4. Sub-category Certi cate (CW/PH ) as applicable



18. Undertakings by the Candidates(a) I hereby certify that the foregoing particulars are correct and I agree that admission may be granted to me on the

terms, conditions and rules of the DTU or such modi cations thereof as may be made by authorities concernedfrom time to time. I understand that my admission may be cancelled and tuition fee paid by me forfeited if any of the particulars given by me in this application are subsequently found to be wrong.

(b) I agree that Vice-Chancellor decision in all matters concerning my admission, studies, discipline and conduct will be nal and binding on me.

(c) I have not left any Engineering Degree course or an equivalent course after exhausting the permissible number of chances in any other University / Board.

(d) I understand that my association, active or passive, with any unlawful organization is forbidden.

(e) I am not registered/enrolled for any other course of any other University or I am registered for ......................................................... course of .................................................. University / Institution and undertake that I shall

withdraw my admission if admitted in DTU.

(f) I agree that the DTU shall have the right to forfeit the security deposits inter alia on the ground of my failure toclaim the refund within one year of the date of my ceasing to be on the rolls of the DTU.

Date: .........../............/2010 Signature of the Applicant

19. Undertakings by Parents / Guardian(a) I testify that my son / daughter / ward ....................................................................... is seeking admission with my

consent and I am personally responsible to the University for payment of all his/her dues as the Vice-Chancellor may decide. I assure that the applicant will abide by the rules of the University as laid down by the Vice-Chancellor,Delhi Technological University (DTU).

(b) I have read the rules and I understand that my son/daughter/ward has to undergo obligatory practical training for speci ed periods in accordance with the relevant Ordinance of the DTU. I agree that in the event of my ward being

placed in an industrial installation outside Delhi for such practical training. I will not raise any objection for his/her being so placed.

(c) I hereby certify that the foregoing particulars furnished in this application form are correct.

Date: .........../............/2010 Signature of the Parent / Guardian

Place : ............................... Name

Address

Pin Tel. (R)Tel (O) Mob.



Medical Fitness certiFicate(To be signed by a registered medical practitioner holding a degree not below that of M.B.B.S.)

(to be subMitted at the tiMe oF adMission)

(r f p 3.16 f P p )

I certify that I have carefully examined Mr./Ms. * .................................................

Son/Daughter of Shri ........................................................................................

whose signature is given below. Based on the examination, I certify that he/she

is in good mental and physical health and is free from any physical defects which

may interfere with his/her studies including the active outdoor duties required of a professional.

Mark of Identi cation ................................................

Signature of the candidate ......................................

Place : Name & Signature of theMedical Of cer with seal

Date : and Registration Number

*strike whichever is not applicable.

application form for admission to b

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